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Lannett: JCUW Annual Campaign 2023

Lannett: Online Giving

First Name *

Last Name *

Phone *

Birth Date

Street Address

City

State

Postal Code

Leadership Giving

Booster $1,000

Merit $1,500

Pacesetter $3,000

Jackson Society $5,000

National Tocqueville Society $10,000+

Please choose the amount per pay period you would like to give to help the community!

I want to contribute the following amount per pay period *

$5
$10
$15
$25
$50
Fair Share (one hour's pay per month)
Same Donation Amount Last Year
Other

Pay Periods *

Weekly (52 payments)

Biweekly (26 payments)

Monthly (12 payments)

Other Amount

For one time credit card gifts, select the amount from above and put card information in here. You will only be charged one time.

Credit Card Information

If you have selected fair share (one hours pay per month) please list your hourly pay.

Fair Share Amount

Please list anything that you'd like United Way to know about your gift.

Notes/Comments

Please sign electronically to verify your gift.

Signature Text

PO Box 94
209 E 2nd St. Suite B
Seymour, IN 47274
812-522-5450